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Referred by
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Treating Dx
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Note visit type
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Note service type
• • •
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SUBJECTIVE
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Recent Subjective Finding
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History
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Medical/Social Hx &/or Co-Morbidities (that may affect recovery)
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Personal health rating: "At the present time, would you say that your health is___________
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PAIN
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Approximate date of onset
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Type of Pain
• • •
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Verbal pain rating at present____/10
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Pain frequency
• • •
|
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Verbal pain rating at worst____/10
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Verbal pain rating at best____/10
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Aggravating factors
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Relieving Factors
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How much have your symptoms interfered with your daily activities?
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OR
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Exact onset date
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Cause of current episode
|
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Recent symptom trend
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Surgery Date
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ASH Items
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Treatment start date (initial eval date)
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Stage of condition
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Nature of condition
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OBJECTIVE
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Palpation & Inspection
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|
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VITAL SIGNS
|
|
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Height
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Weight
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Blood pressure
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OUTCOME MEASURE TOOLS
|
|
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Back index
|
Note
|
|
ADL PROBLEMS
|
|
|
ADL Problems
• • •
|
Others, please specify
|
|
ORTHOPEDIC TESTS
|
|
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Slump Test - Result
|
Note
|
|
Roos's - Result
|
Note
|
|
Rib Springing - Result
|
Note
|
|
Other orthopedic tests
|
|
|
THORACOLUMBAR ACTIVE & PASSIVE ROM
|
|
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Thoracolumbar extension (AROM normal 25°) - current
|
Thoracolumbar extension (PROM normal 25°) - current
|
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Thoracolumbar flexion (AROM normal 80°) - current
|
Thoracolumbar flexion (PROM normal 80°) - current
|
|
Thoracolumbar left lateral flexion (AROM normal 35°) - current
|
Thoracolumbar left lateral flexion (PROM normal 35°) - current
|
|
Thoracolumbar right lateral flexion (AROM normal 35°) - current
|
Thoracolumbar right lateral flexion (PROM normal 35°) - current
|
|
Thoracolumbar left rotation (AROM normal 45°) - current
|
Thoracolumbar left rotation (PROM normal 45°) - current
|
|
Thoracolumbar right rotation (AROM normal 45°) - current
|
Thoracolumbar right rotation (PROM normal 45°) - current
|
|
MUSCLE STRENGTH
|
|
|
Trunk Extension
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Trunk Flexion
|
|
L Trunk Rotation
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R Trunk Rotation
|
|
Neuromuscular patterns
|
|
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ASSESSMENT
|
|
|
Short term goals
|
Long term goals
|
|
TODAY'S TREATMENT
|
|
|
Therapeutic Exercise: (97110)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Manual Therapy: (97140)
|
Total time
|
|
Note
|
Rationale for manual therapy
|
|
Neuromuscular Re-Education: (97112)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Therapeutic Activities: (97530)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Ice: (97010)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Heat: (97010)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Electric Stimulation: (97014)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Ultrasound: (97035)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Gait Training: (97116)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Review of HEP
|
Notes
|
|
TAPINGS
• • •
|
|
|
PLAN
|
|
|
PLAN OF CARE
|
|
|
Frequency
|
Duration
|
|
Treatment
• • •
|
Discharge note
|
|
ICD-10 CODES
|
|
|
Medicare Functional Limitation
|
|
|
Code Category
• • •
|
Code Status
• • •
|
|
Treating Provider
|
Supervising Provider
|
